245 Febrile Neutropenia Treatment in the Emergency Department: Overtreatment and Unnecessary Hospital Admissions are Common

Abstract

Febrile neutropenia (FN) is an oncologic emergency associated with a risk of major complications and mortality. The objective of this study is to assess adherence to the Infectious Diseases Society of America (IDSA) guidelines for the use of antimicrobial agents in neutropenic patients with cancer as well as the outcomes associated with treatment administered to febrile neutropenic patients in the emergency department. This was a single center, observational cohort study conducted at a 60,000 visit Midwestern tertiary referral ED in febrile neutropenic patients between January 2009 to July 2018. Patients included were > 18 years of age, had an ANC < 500/mm3, and were febrile (>38°C). Patients were excluded if they had no concomitant cancer diagnosis or had a suspected source of infection. The primary outcome of this study was proportion adherence to the current febrile neutropenia guidelines. Secondary outcomes included 30-day mortality, hospital length of stay, appropriate vancomycin administration, culture results, rates of acute kidney injury (AKI), and C. difficile infections. Low-risk patients were defined as those with a MASCC score of > 21, while high-risk patients were defined as those with a MASCC score of <21 or >21 and a clinical indicator for admission. Adherence to the guidelines was defined as hospital admission with intravenous (IV) broad-spectrum antimicrobial therapy for high-risk patients and discharge to home with oral antimicrobial therapy for low-risk patients. Vancomycin appropriateness was determined using the IDSA febrile neutropenia guideline recommendations. Acute kidney injury was determined using the current Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Relative risks of each demographic and clinical characteristic were assessed predicting adherence. A total of 237 patients were included in this study, 94 low-risk patients and 143 high-risk patients. Nonadherence to the guidelines occurred in 91 (96.8%) low-risk patients and 1 (0.4%) high-risk patients. The mean hospital length of stay for patients in the low-risk group was 5 ± 5.0 days compared to 7.2 ± 7.3 days in the high-risk group. Eighty-nine (94.7%) low-risk patients received broad-spectrum antimicrobial therapy. The 30-day mortality rate was 2.9% in low-risk patients and 16% in high-risk patients. Vancomycin was administered to 38.4% of patients (59 (41.3%) high-risk and 32 (35.2%) low-risk patients) In the high-risk patients, vancomycin administration was inappropriate in 42 (71.2%) of the cases. C. difficile occurred in 10 (10.6%) low-risk patients and 4 (2.8%) high-risk patients. Adherence to the febrile neutropenia guidelines was low, particularly in the low-risk population resulting unnecessary hospital admissions and receipt of inappropriate broad-spectrum antimicrobials. Future studies should focus on evaluating the impact of information technology and educational opportunities to improve guideline adherence for the management of febrile neutropenic patients presenting to the ED.